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<\/p>\nThe system has you convinced it\u2019s malfunctioning. That\u2019s how it protects itself.<\/p>\n
\u201cI don\u2019t think this is a crisis of the system,\u201d said Omar Gabriel Torres Valencia, a primary care physician, historian, and until recently a policy advisor at King\u2019s Global Health Partnerships, speaking on the BMJ\u2019s Medicine and Science podcast. \u201cI think we\u2019re seeing, finally, sadly, very nakedly, the system operating in the way that it is intended to work.\u201d<\/p>\n
His diagnosis \u2014 co-developed with Daniel Bernal-Serrano, a physician and PhD researcher at the London School of Hygiene and Tropical Medicine, and Niral Maritia, based in Indonesia \u2014 takes aim at the global health reform agenda itself. Their new BMJ analysis argues that every major reform proposal fails for the same reason: it refuses to name the economic system producing the pathology it claims to treat. And that omission, they say, is not an oversight. It\u2019s the architecture\u2019s most effective defense.<\/p>\n
A revolving door with a billing code<\/p>\n
Torres Valencia reaches for a clinical analogy. In emergency medicine, there\u2019s the revolving-door patient \u2014 someone with diabetic ketoacidosis who\u2019s treated, stabilized, and discharged, only to return days later in the same crisis. Nobody asks whether they can afford insulin once they leave the hospital. The system treats the acute episode because that\u2019s what it\u2019s built and reimbursed to do. The chronic driver \u2014 poverty, underinsurance, insulin priced beyond reach \u2014 sits outside the treatment window.<\/p>\n
Global health performs the same maneuver, he argues, treating within the rules of a system \u201cwhose primary goal is the accumulation of profit, and that is just substantially contrary to human and planetary well-being.\u201d<\/p>\n
The vocabulary took courage to deploy. Bernal-Serrano admitted the authors initially censored the word \u201ccapitalism\u201d from early drafts, fearing it would disqualify the article before it reached a readership. Host Jocelyn Clark, BMJ\u2019s international editor, noted dryly that capitalism is more than welcome at the journal. The larger point, Torres Valencia said, is that the same self-censorship pervades global health meetings \u2014 and that\u2019s precisely why reform documents keep proposing technical adjustments rather than structural ones. Political economy analysis exists to break that silence.<\/p>\n
<\/p>\n
Three pillars nobody\u2019s reform touches<\/p>\n
If the system is working as designed, the article\u2019s job is to map the design. The authors identify three structural mechanisms that convert health need into private value \u2014 each embedded in the architecture\u2019s power arrangements, each untouched by the fashionable reform language of country sovereignty and self-sufficiency.<\/p>\n
PillarMechanismHealth consequenceEvidence citedIntellectual property regimePublicly funded research converted into private patents; one holder controls accessLife-saving products rationed by market logic, not needmRNA vaccines built on decades of taxpayer-funded science were patented; much of the world denied accessSovereign debt architecturePost-colonial states saddled with loans conditioned on repayment and public-sector privatizationDebt service crowds out health and education budgets3.4 billion people live in countries spending more on interest than on health and education combined; ~$3.5 trillion extracted from the Global South, 1960s\u20132018Commodification of healthPrivate capital acquires core health-system functions and manages them for profitCare decisions skew toward profitability; cost-cutting erodes qualityPrivate equity buying UK clinics and care homes; donor preference for profitable technology platforms over health-system strengthening<\/p>\n
The IP mechanism is the most naked. Torres Valencia points out that mRNA vaccines were not invented in a year. The platform rested on decades of public investment, taxpayer money from multiple countries, and clinical trials conducted on diverse populations. On that logic, the vaccine should have been a public good. Instead, it became intellectual property with a single keyholder.<\/p>\n
\u201cIt is basically like building a house with the help of all the community, using the resources of everyone,\u201d he said. \u201cAnd then suddenly, only one person holds the key, and they get to decide who goes in and who doesn\u2019t get to go in.\u201d<\/p>\n
Innovation, he adds, is not something capitalism invented. It exists in societies that don\u2019t adhere to capitalist premises \u2014 from indigenous communities to historical examples. The question is where the innovation pipeline points: toward need or toward profit.<\/p>\n
The debt architecture has the longest historical roots. Bernal-Serrano frames it as development deliberately arrested. Colonial empires extracted resources, then the same countries were told aid would arrive \u2014 conditioned on repayment with interest and on restructuring their own governments. \u201cHaiti should have no debt at all,\u201d he said, given what the developed world extracted from it. Torres Valencia cited research led by economist Jason Hickel tracing extraction from the Global South between the 1960s and 2018 at roughly $3.5 trillion \u2014 a sum that dwarfs official development assistance. Current reform efforts, Bernal-Serrano stressed, do not even demand reparation.<\/p>\n
Multilateralism\u2019s vacancy, private power\u2019s inheritance<\/p>\n
The reform agenda never reaches those pillars because the architecture encodes the power of its founders. The post-war order was built by the victors of a conflict that killed roughly 80 million people, and its symbols are projections of that victory: permanent Security Council seats, the UN headquartered in New York, Geneva, and Vienna. The promise \u2014 that states and peoples would be treated as equals \u2014 was, Torres Valencia said, never kept. The victors are unwilling to share power, and the West is in the middle of what he calls a \u201ccivilisational crisis.\u201d<\/p>\n
The disorder has accelerated visibly since Donald Trump\u2019s return to the US presidency, most starkly in the dismantling of USAID, with Elon Musk operating inside the state apparatus. Clark\u2019s phrase: \u201cwoodchipping USAID.\u201d<\/p>\n
With Washington retreating, the expected backfill isn\u2019t arriving. The UK, Canada, Australia, and European states have all pulled back development aid. China, despite its bilateral relationships, isn\u2019t stepping into the multilateral breach. The actors best positioned to occupy the vacuum are non-state ones \u2014 and the authors are specific about what that means.<\/p>\n
ActorObserved behaviorEffect on global health powerTrump administrationCuts global health funding; USAID dismantledAccelerates the multilateral vacuumElon MuskHeld a state role dismantling USAIDPrivate power executing state functionsUK, Canada, Australia, EuropeRetreat from development aidThe donor backstop assumed by reform plans is not materializingChinaPursues bilateral relationshipsDoes not fill the multilateral voidGates FoundationPositions itself as funder of last resortLargest private donor, but directs money toward profitable technology platforms<\/p>\n
The Gates Foundation has saved millions of lives, Bernal-Serrano acknowledged \u2014 \u201cincredibly.\u201d But when the choice is between governance interventions and horizontal health-system strengthening on one side, and technological innovation on the other, it invests in the latter. \u201cIn the end, these technological innovations are sources of profit.\u201d<\/p>\n
Torres Valencia draws the deeper institutional distinction. States exist to guarantee safety within a social contract. International organizations exist to guarantee rights regardless of nationality. A private foundation or company operates under the logic of capital, and \u201cmost of the times\u201d profit maximization is directly at odds with social benefit. Rationing vaccines can be a profit-maximizing decision. \u201cWe are seeing it already.\u201d<\/p>\n
Daniel Bernal-Serrano offered a sharp prediction: as state donors withdraw, non-state actors like the Gates Foundation and Elon Musk will gain significantly more power in global health without having to increase their own investment. The vacuum itself is the asset.<\/p>\n
\u201cThis is literally us letting a patient die\u201d<\/p>\n
If the system runs as designed and private power is its heir, then someone is responsible. That brings the authors to their most confrontational framework: social murder.<\/p>\n
The term traces back to Friedrich Engels, who used it to describe deaths caused by social arrangements rather than natural forces. BMJ editor Kamran Abbasi revived it in a 2021 editorial to describe the preventable COVID-19 deaths that lay \u201cat the feet of political leaders\u201d in the UK. The authors extend the concept to global health because it does two things that technical reform language refuses to do: it marks deaths as willful, deliberate, and avoidable, and it assigns accountability.<\/p>\n
Torres Valencia made the distinction visceral. \u201cThis is not someone coding in the emergency department and us breaking their ribs because we\u2019re trying to keep them alive,\u201d he said. \u201cThis is literally us letting a patient die because it\u2019s more profitable to let them die.\u201d<\/p>\n
Clark pushed the point toward its constructive conclusion: if these outcomes are the product of decisions, they are not inevitable. That\u2019s precisely why the framing matters. Accountability is the precondition for change.<\/p>\n
Private equity\u2019s three-to-five-year extraction cycle<\/p>\n
The second half of the episode shifts scale \u2014 from global architecture to national market structure \u2014 but the operating logic is identical. Bernd Rechel of the European Observatory on Health Systems and Policies explained that European health ministries approached his team with a single question: \u201cHere\u2019s something happening with private equity. Can you have a look at what is happening in other countries?\u201d<\/p>\n
His definition is precise. Private equity funds are pooled investment vehicles that acquire companies, manage them, and plan to resell within three to five years at a profit. The UK is now the second-largest PE healthcare market after the US, with healthcare\u2019s share of all PE deals doubling from one in ten a decade ago to one in five today.<\/p>\n
Why healthcare? Because it\u2019s stable and state-backed. Health spending as a share of GDP has risen continuously across Europe and will keep rising. Sectors like dental and eye care are fragmented enough that a fund can acquire practices, consolidate, and expand market share. The model loads acquired companies with debt, cuts staffing \u2014 the largest expenditure \u2014 and expands rapidly through acquisition. Then it sells.<\/p>\n
Each step has real-world precedents, Rechel noted. Staffing cuts hit workers first and quality second. Debt-loaded facilities face bankruptcy and closure. Monopoly positions enable price increases. Underserved areas lose their providers entirely, producing access gaps and unmet need.<\/p>\n
\u201cWe are not saying all private equity firms are evil and devious,\u201d Rechel said. \u201cBut we say there are some risks inherent in the business model and some incentives that carry greater risks for the health sector than other types of ownership.\u201d<\/p>\n
The problems aren\u2019t unique to private equity. Host Shivali Fulchand raised the editorial\u2019s example of patient restraint in mental health facilities, and Rechel conceded such harms occur under public ownership too. Quality-control mechanisms should apply to all providers \u2014 but they\u2019re especially necessary where the profit motive sharpens the incentive to cut corners. In residential long-term care for older people, he added, it\u2019s genuinely difficult to control what happens inside facilities regardless of owner.<\/p>\n
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<\/p>\n
The regulatory counteroffensive<\/p>\n
Pushback is already visible across Europe \u2014 and the measures are more aggressive than the reform proposals Bernal-Serrano and Torres Valencia criticize at the global level.<\/p>\n
JurisdictionMeasureStatusUK \u2014 Andy BurnhamExclude private equity from social care entirelyPolitical proposal, following scandals in children\u2019s and care homesGermanyBan private equity in healthcarePromised by health minister; government collapsed before legislation passedNetherlandsResidential nursing homes barred from making a profitPrecedent for not-for-profit private provision; calls for a wider banIrelandGovernment guarantees public long-term care in areas investors avoidPublic provision used as corrective after PE scandalsAustria (some federal states)Favor public provisionStructural preference at state levelUS (one state)Attempted legislative ban on private equity in healthcarePart of widening debate<\/p>\n
The funding-gap argument for private equity \u2014 that it brings needed capital \u2014 Rechel rebutted directly. The model loads acquired facilities with debt, which removes capital, and then extracts profits out of the health system entirely. The net inflow is far smaller than the gross numbers suggest. The alternative is not necessarily public-only provision. It\u2019s for-profit exclusion, not-for-profit private provision on the Dutch model, or deliberate public provision in exactly the areas the market won\u2019t serve, as in Ireland.<\/p>\n
One logic, two scales<\/p>\n
The two conversations cover materially different subjects \u2014 the global health architecture and the UK market for private equity \u2014 but they reach the same diagnostic conclusion. In both, the system\u2019s failures are not malfunctions; they are the system working as programmed.<\/p>\n
At the global level, the program is an IP regime, a debt architecture, and the commodification of care working together to transfer value from the sick and the poor to the powerful. In UK healthcare, the program is a three-to-five-year holding period that converts care facilities into debt-laden assets flipped for profit. In both, the assumed rescuer \u2014 the wealthy philanthropist, the private equity fund, the future donor \u2014 is the entity whose incentives created the problem. The remedy is not to invite them deeper but to make their extraction politically costly.<\/p>\n
Organizing, not pleading<\/p>\n
The authors\u2019 most deliberate rhetorical choice is the closing line they refused to write. \u201cWe deliberately choose not to close our paper with a call for political will,\u201d Bernal-Serrano said. Clark called the convention shallow. The authors implied it\u2019s a dodge that fails \u201cthe historical and political moment.\u201d<\/p>\n
What replaces it? Concrete mechanisms of pressure. Bernal-Serrano pointed to the NHS as proof that organized resistance works. Repeated pushes to commodify it were stopped by health professionals and, \u201cvery importantly,\u201d civil society. The actionable version for a jobbing health professional or student: understand what is happening and why, then \u201corganize, speak up, and really stop capitalists in their tracks when they want to financialize or capitalize or commodify our health system.\u201d<\/p>\n
Torres Valencia acknowledged that people working inside institutions self-censor to protect their positions \u2014 and appealed instead to the \u201cpolitical latency that exists within health workers\u201d and to their moral conscience. The leverage principle: act so that it becomes costlier for governments and multilateral organizations not to act than to act.<\/p>\n
\u201cIn the end, what we can or cannot do is not defined in our mind, but by what we can imagine,\u201d Bernal-Serrano said.<\/p>\n
For investors and policy professionals, the episode\u2019s core warning is that every funding gap in global health is simultaneously an investment thesis. The question is who writes the terms \u2014 and whether organized health workers and civil society can rewrite them before private power consolidates permanently into the architecture\u2019s vacant seats.<\/p>\n","protected":false},"excerpt":{"rendered":"The system has you convinced it\u2019s malfunctioning. That\u2019s how it protects itself. \u201cI don\u2019t think this is a…\n","protected":false},"author":2,"featured_media":67576,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[6],"tags":[26784,26777,26778,26776,14517,26783,26780,26785,26786,26779,26782,26775,26781,95],"class_list":["post-67575","post","type-post","status-publish","format-standard","has-post-thumbnail","category-valencia","tag-andy-burnham","tag-bernd-rechel","tag-bmj","tag-daniel-bernal-serrano","tag-elon-musk","tag-european-observatory-on-health-systems-and-policies","tag-gates-foundation","tag-jason-hickel","tag-kings-global-health-partnerships","tag-london-school-of-hygiene-and-tropical-medicine","tag-nhs","tag-omar-gabriel-torres-valencia","tag-usaid","tag-valencia"],"_links":{"self":[{"href":"https:\/\/www.europesays.com\/spain\/wp-json\/wp\/v2\/posts\/67575","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.europesays.com\/spain\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.europesays.com\/spain\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/spain\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/spain\/wp-json\/wp\/v2\/comments?post=67575"}],"version-history":[{"count":0,"href":"https:\/\/www.europesays.com\/spain\/wp-json\/wp\/v2\/posts\/67575\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/spain\/wp-json\/wp\/v2\/media\/67576"}],"wp:attachment":[{"href":"https:\/\/www.europesays.com\/spain\/wp-json\/wp\/v2\/media?parent=67575"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.europesays.com\/spain\/wp-json\/wp\/v2\/categories?post=67575"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.europesays.com\/spain\/wp-json\/wp\/v2\/tags?post=67575"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}